Resisting Twelve-Step Coercion

In practice scientific knowledge has little impact on addiction treatment in the U.S. and psychologists typically play a small role in addiction treatment.

Inside of prisons, inmates are forced into AA groups and programs based on them. Sometimes the treatment is required as a part of sentencing. Often, it is made clear to the inmate that AA attendance is required in order to gain parole. In addition, other state-run programs, for example, social support programs, frequently require clients to undergo such treatment. The cost of refusal here are expulsion from the program and termination of benefits.

The trend in U.S. courts is ever more in this direction. The creation of drug courts as alternatives to ordinary court proceedings and the substitution of treatment for criminal sentencing are becoming the norm. In part, this development is an improvement over repressive sentencing of drug users. Non the less, such coerced treatment carries many of the negative consequences of jail sentences, and it has additional drawbacks in terms of personal freedoms and the right to define once inner life.

The disease model of alcoholism that underlies AA and 12 step treatment programs has an explanation for the need for such coercion: Alcoholics are in “denial”.

Further more, many people, especially young people display sometimes severe substance abuse problems, but then outgrow them, this process is so ordinarily that it has been given the common place name, “maturing out”.

Maturing out will occur far more often than not – unless drug, alcohol treatment and education persuade many individuals who would otherwise do so that they cannot escape youthful drinking and drug excesses.

Much of the pressure for expanding coercive drug treatment is due, oddly enough to the failure of current drug policies. Since there is a pervasive sense that we as a society are barking of the wrong tree, with punitive laws that punishes simple possession or use of drugs with imprisonment, treatment becomes an attractive alternative.

Our view is that compulsory treatment is wrong and ineffective. In no area is it’s emergence -once a science fiction topic, as in a clockwork orange- more real than in present days substance abuse treatment.

Efficacy of 12-step Groups

The massive American treatment enterprise is based on the believe that alcohol and drug abuse can be treated away, and that we know how – and are currently able – to do so. Research has repeatedly questioned whether the standard elements of U.S. substance abuse treatment work, and indeed, sometimes indicates that they do more harm than good.

There have been a number of control studies of AA and 12 step treatment but there have been no scientifically valid, generalizable studies of NA. That is, there have been no studies of NA featuring random assignment of subjects and no –treatment control groups, or even comparison groups given other treatments, nor have there been longitudinal studies with match comparison groups.

So, ignoring the ungeneralizable, uncontrolled studies cited by AA’s supporters, and the self-serving, gross overestimates of treatment effectiveness by treatment providers, what are we left with? There is no scientifically valid evidence of NA’s effectiveness. To put it another way, those being coerced into NA are being coerced into a program for which there is no scientific evidence of efficacy.

Finally, it is important to point out, that the increase in binging behavior among those exposed to AA in this study militates against coercing DUI offenders into AA attendance. One very possible reason for the increase in binging is the emphasis in AA upon inevitable loss of control, after even one drink, as codified in the AA slogan, “one drink, one drunk”. What likely happens is that those exposed to AA, this inevitable –loss-of-control belief becomes a self-fulfilling prophecy.

Ultimately, eliminating coercion in AA would improve AA’s current dismal effectiveness rate. At the very least, if AA returned to being a voluntaristic organization, it seems likely that it success rate would increase because of the placebo effect and member motivation, or readiness to change.

Amazingly, given its predominance in the $10-billion a year treatment field –there have been relatively few control studies (or long term follow up – longitudinal – studies of people with treated and untreated alcohol problems), involving 12-step treatment.

The Vaillant Study of Harvard University, showed that even among those seeking abstinence, the large majority in Vaillant’s untreated sample succeeded without AA.

Miller, et. al., noted: “A significant negative correlation was found between the strength of efficacy evidence for modalities and their cost, that is, the more expensive the treatment method, the less scientific evidence documenting its efficacy”.

The community reinforcement approach is a behavioral program that organizes an individual’s environment to reinforce sobriety rather than relying on personal commitment or any kind of spiritual or internal resolution of the problem. Such cognitive-behavioral therapy introduces and reinforces new ways of thinking and approaches to problem-solving so that addicts learn alternative ways of copping with stress and insecurity other than turning to drugs or alcohol. This type of therapy relies on practical skills and does not teach drug users that they are addicts with a life-long disease.

In many cases, optimistic claims about treatment are based only on those that complete treatment, which is another way of evaluating only the best-prognosis patients.

It is very important that drop out rates be taken into account when calculating the effectiveness of treatment programs.

As the motivational enhancement results showed such a improvement does not require extensive time in treatment –a couple of hours may be sufficient- In project MATCH, such treatment produced excellent results in a fraction of the time and cost required by standard treatment programs.

Twelve-step devotees would want to report favorable outcomes (probably more so than CB patients, who would not have religious zeal as a motivator).

Normally, in scientific discourse on the treatment of disease, the burden of proof falls on those proposing a treatment. That is, those who assert that a treatment is effective are obliged to provide convincing evidence of its efficacy before it passes beyond clinical studies, let alone is administered on a mass scale.

The devotees ignore the available scientific studies and offer virtually no evidence beyond anecdotal claims and uncontrolled studies, yet continued to trump it 12-step groups and 12-step treatment as the best, if not the only, means of dealing with addiction problems. It is a telling sign that their advocacy of the $10-billion dollar a year frequently coercive 12-step industry is not a matter of standard medical evaluation. Rather, their support for this approach is most likely a matter of religious belief and/or financial interest.

Is Abstinence Necessary?

This adherence to abstinence is routinely enforced by mandatory urinalysis (or at least, the threat of it). Why should anyone be forced to such indignities and to suffer such drastic penalties for taking so much as a single drink? The answer lies in the 12-step alcohol treatment ideology and its influence on public policy. It has become an article of faith in the American alcoholism treatment industry that abstinence is the only acceptable treatment goal.

All of the studies -but specially the long term studies such as: NLAES, McCabe and Finney and Moos- provide powerful evidence that abstinence is not the only way to beat an alcohol problem, and that the disease concept of alcoholism, with its loss of control believes and claims of inevitable progression of alcohol problems is simply unfounded assertion. Thus, it seems grossly unfair –in fact, a crime- that individuals are routinely coerced into total abstinence and suffer drastic consequences if they take so much as one drink, in the complete absence of scientific evidence that total abstinence is necessary. Further more, the opportunity to select and pursue a treatment goal –whether abstinence or controlled drinking- enhances the likelihood of success.

The research consistently indicates that a substantial number of former alcohol abusers, and alcohol-dependent persons resolve their problems through moderation, rather than abstinence. It also indicates that there is simply no justification in a large majority of cases for coercing anyone into total abstinence; and the evidence also indicates that the often barbaric penalties inflicted upon persons who have as little as one drink are unjustified.

What Works?

America’s present, religiously based alcohol-abuse treatment system is a dismal failure. It is extremely expensive, massively coercive, apparently no more effective than the rate of spontaneous remission, and has blocked the implementation of more effective alternatives.

CRA (Community Reinforcement Approach)

The basic premise of the CRA most often a one-on-one therapy, although it can be used in group settings, is that alcohol abuse does not occur in a vacuum, that it is highly influenced by marital, family, social, and economic factors (the exact opposite of the AA premise that alcoholism or drug addiction is purely an individual disease that exists independently from other conditions. CRA attempts to help the client improve his or her life in all of these areas. Thus a CRA program will typically include the following components:

Social skills training: This form of group therapy is another very well supported approach. The basic premise of social skills training is that alcohol and drug abuse clients lack the basic skills in dealing with work, family, or other interpersonal relationships, and their own emotions. They receive training in such areas as communication skills, conversational skills, conflict resolution, drink-refusal, assertiveness, and expressing feelings.

Brief intervention: These shares elements with motivational enhancement in that the client and the therapist create a mutually agreed upon goal. The key is to allow patients to select a goal that is consistent with their own values and that they thus “own” and as expression of their genuine desires.

If drug and alcohol abusers become properly involved in defining and directing their own efforts towards change; that is, they will likely succeed if they want to change, and if they have support in their efforts to change.

Religion: Concern over what exists beyond the visible world, differentiated from philosophy in that it operates through faith rather than intuition.

The definitions of religion vary considerably, but they have several things in common, the most important being belief in God.

AA’s literature with its repeated mentions of God, the importance of belief in God, and its exhortations to pray to God – not to mention AA meetings with their public prayers witnessing collections, and confessions- provide convincing proof that AA is a religious organization.

Thus AA meetings normally open with a prayer to God, directly meeting 2 of the 4 criteria of religious activity (belief in God and ritual). Then the speaker will begin with a lurid and prolonged description of his drinking behavior and how it led to his downfall. People then describe the shame and hopelessness he felt as a drinking alcoholic, and how at last he went to an AA meeting.

Going beyond the steps, religious elements abound in the Big Book. It devotes an entire chapter to attacking atheists and agnostics as being crazy and to presenting belief in God as the only way to restore “sanity”.

Anyone who accepts that Bill Wilson was divined guided when he wrote the 12-steps must necessarily grant those steps the status of revealed wisdom. This places Wilson on the level of the old testament prophets, and the Big Book on the level of scripture.

The purpose of the 12-steps has indicated by Wilson, is not only to lead individuals to belief, but to have them turn their wills and lives over to the God to which the steps lead them. In his discussion of step 4, making “a searching and fearless moral inventory”, Wilson makes an extraordinarily suggestion: that once inventory of moral “defects” be based on a universally recognized list of major human failings – the seven deadly sins of pride, greed, anger, lust, gluttony, envy and sloth.

Contrary to Wilson’s assertion, these are not “universally recognized list of major human failings” rather, they are a specifically Christian list of sins coming straight out of the Church of the middle ages. To point out the obvious, many atheists and agnostics would consider every single one of these universally recognized failures as far less loathsome than cruelty –which Wilson does not list as a universal recognized character defect- and almost certainly as no worse than hypocrisy. By sticking to his specifically medieval Christian list of defects, he points out the Christian origins and orientation of the 12-steps.

There is in AA deistic belief in AA, there is a centrality of suppression of self and suppression of self direction that AA is particular type of deistic belief involves.

The result of all this indoctrination –religious indoctrination into the divinely guided “AA way of life”. As Bill Wilson himself noted “I don’t need religion, because AA is my religion”.

The Courts and Coerced 12-step Attendance

Uniformly the courts have ruled that mandated 12-step attendance violates the first amendment of the U.S. constitution. The bill of rights begins with the statement “Congress shall make no law respecting the establishment of religion or prohibiting the free exercise there of…” The first part of this statement is called the “establishment clause” However, to date, no court has ruled against an employers forcing an employee attending 12-step therapy.

KERR V. Farrey (1996).
The U.S. Court of appeals for the 7th circuit reversing a district court decision unanimously held “that the state… impermissibly coerced inmates to participate in a religious program, thus violating the Establishment Clause”.

The establishment of religion clause of the 1st amendment means at least this: neither a state, nor the federal government can set up a church. Neither can pass laws which aid one religion, aid all religions, or prefer one religion over another. Neither can force, nor influence a person to go to or to remain away from church against his will or force him to profess a belief or disbelief in any religion. No person can be punished for entertaining or professing religious believes or disbelieves, for church attendance or non-attendance.

Kerr alleged, that the meetings were permeated with explicit religious content. Thus, the program runs afoul of the prohibition against the states favoring religion in general over non-religion.

Kerr attempted to tackle the immunity issue again in order to gain a damages award by accusing the prison drug rehabilitation programs administered by the Wisconsin prison system of brainwashing, which he claimed constituted cruel and unusual punishment, in violation of the 8th amendment.

Based on existing precedent, courts are obligated to require alternatives to AA and 12-step programs, and specifically non-religious alternatives, such as SMART recovery and Rational Recovery. When people are required to create and follow programs of their own choosing, of course, society and its agencies can properly require adherence to designated programs and responsible behavior as conditions of continued freedom.

AA and the Establishment Clause

“The supreme court has repeatedly made clear that –at a minimum the constitution guarantees that the government may not coerce anyone to support or participate in religion or its exercise…” Lee v. Weisman.

In the highest courts at which the issue has been decided, 12-step treatment programs and groups, including AA, NA, et al. have been determined to be religious activities that the state cannot legally compel individuals to attend. These decisions are based on the 1st amendment of the constitution, and in particular its establishment clause barring the state from supporting and especially from compelling, religious activities.

In many cases, making responsible individuals aware of what the law has to say about the need to provide people with alternatives to 12-step groups rather than to coerce them to attend such groups –as well as making them aware of practical alternatives for meeting legal requirements- should stimulate a willingness to explore change. The alternative, to attempt legally to compel such change, is a last resort.

We have found that the most reasonable prison officials and others in the penal system respond to the simple logic that different people respond to different kind of programs.

If the case concerns you, you can say that the religious element in AA violates your believes and convictions.

Informed Consent: Missing in Addiction Treatment

Besides competence, two other elements are necessary to informed consent: information and voluntaries. In order to make an informed decision, a person must be informed about the nature of the treatment offered, its risks and benefits and possible alternative treatments.

In addition to its legal and ethical basis, informed consent should be a clinical imperative. A growing body of research shows the predictable result that patients participated more fully in treatment and experienced better outcomes when they have the opportunity to choose a form of treatment they believe in.

When a case is brought against a physician on a theory of informed consent, the mere failure to obtain required informed consent is sufficient to establish liability.

In one case Dr. Talbott past president of ASAM was found liable for 1.3 million in actual damages because he coerced the client into alcoholism treatment through threats to his medical license, combined with a bogus diagnosis of alcohol dependence. Talbott and a number of colleges were found liable for fraud, malpractice and false imprisonment.

It is AA’s belief that alcoholics only alternatives to AA are “jails, institutions or death”.

State laws provide that if a mentally ill person is to be deprived of the right to make personal choices including that of giving informed consent to treatment, a court hearing must be held to determine if the person is incompetent. As a rule, in an involuntarily committed person is presumed competent unless a court rules otherwise.

ASAM’s principles of medical ethics are meaningless.

The principles note that the physician has the duty to uphold patients rights while working in an interdisciplinary team and “should not delegate to any non-medical person any matter requiring the exercise of professional medical judgment”. ASAM physicians typically hand off patients to recovering alcoholism counselors, that is: AA members with little if any medical training.

The answer to these abuses may be that as demonstrated in Masters v. Talbott, juries can respond to the blatant violation of individual rights, medical principles and therapeutic responsibility that pervade American addiction practice. Multimillion dollar judgments may be the only argument that true-believing coercing “addictionists” will understand.

A coerced individual should insist on receiving a formal, written diagnosis, whether alcohol dependence, abuse, or problem drinking. This document allows the individual to have another expert independently evaluate the diagnosis.